Chinese Health Care: The Hyppocritic Oath

Within days of my arrival in China a year ago, I had the chance to see inside a local Harbin hospital with my fellow new arrivals. This trip was part of "standard procedure" for getting a work visa, which isn't actually all that standard because I arrived on a tourist visa, and once inside the country, one isn't supposed to be able to switch visas willy-nilly. However, that's exactly what we were doing, so early on it was apparent that guanxi (关系) - one's personal connections - was indeed the powerful force we'd heard it described as... though we didn't fully understand it just then.Having lived in China for a little over a year, I feel like I understand now. Enough so that I can confidently state that guanxi is not as easy to define as people would like. When looking around for a good page to link to, it became apparent that the articles I found touch upon various aspects of it, but fail to grasp the Big Picture. To define guanxi simply as "networking" doesn't address its power; to define it as an "old-boys' network" betrays that it can be used by common folk in their daily lives; to define it as "corruption" is to focus only on one negative result of it. That said, the best attempt to describe guanxi I've found is the following:

Guanxi translated means "relationships." This understanding, in as far as it goes, is common to all humanity and is not cultural specific. In China, guanxi is a system of interpersonal relationships that has long historical and cultural roots. Guanxi is understood and utilized by virtually every Chinese person alive today in greater or lesser measure. The basic underpinnings of the guanxi system are the twin understandings that, one, all things are relative and, two, that people are the deciders of all things. This worldview, as opposed to the concept of the rule of law, is a fundamental distinction between how Chinese and Westerners perceive the world and the appropriate starting place to understand guanxi. China has never been a nation of laws. All of the Western philosophical understandings that define the relationships between individuals and the individual and the society are not present in Chinese society except in the form of shallow, recent transplants. The deeper current still predominates and perhaps always will. (From http://www.gcis.com.cn/China/Regarding%20Guanxi.htm)

One concrete example I can offer you is the following story from my Chinese tutor. His mother's brother was in a nasty car crash and after being taken to the hospital, the doctor told them his leg would need to be amputated. Nobody wanted to believe this, as it would leave him unable to continue his work, and deformities are considered a much more shameful thing here (you almost never see people in wheelchairs, for instance - and Harbin has zero infrastructure to support them). The family couldn't accept this fate and my tutor's father (a doctor, himself) called up the director of the hospital his brother-in-law was at. After this exchange, the director then phoned the leading specialist there to take charge and perform the necessary operations to try and save the leg, in spite of the low chance of success. Luckily, the procedure turned out well and my tutor's uncle was able to keep his leg, which wouldn't have been the case if not for the use of guanxi.

For managing a herd of foreigners, it was much more convenient for our school to have us arrive on tourist visas, and then once we were past the scrutiny of entry and customs, utilize itsguanxi with local officials handling business visas to make the change without much hassle. It's important to note that the visas are valid and were acquired through the official pipeline that anyone else's would be, but think of our approach like yet another common definition of guanxi: "going through the back door."

At this hospital, then, we were undergoing a standard health check. At the time of our arrival in May 2009, the “Swine Flu” (later renamed to H1N1) hysteria was at its most rampant, so many people were wearing face masks and posters appeared on bathroom walls everywhere encouraging the thorough washing of hands with warm water and soap. (Never mind that the bathrooms these were posted in offered neither.) In fact, my flight into Beijing was exceptional: after landing, the doors were kept closed and we weren't allowed to get up right away, and when they finally did open, a camera man and reporter barged in and began asking questions of the flight staff and some passengers. Perhaps luckily, they didn't come my way - I'm not sure if the Chinese would find the same humor in an absurd hacking and coughing routine.

Why not? The government was criticized for reacting slowly to the spread of SARS, so this time around they were trying their damnedest to prevent another outbreak. Since H1N1 was widely regarded as a problem caused by foreigners (and what isn't these days?), we were all under embarrassingly obvious extra scrutiny - even long after customs and immigration. I give credit to Beijing airport for making things less invasive and time-consuming. All arrivals walk through a section of the airport that is lined with heat-sensing cameras for the purpose of identifying any traveller with a fever for further screening. Unfortunately at the time, once symptoms were detected, the only tests that could positively identify H1N1 required waiting a week in quarantine for the results!

Naturally, then, our later screening at the hospital in Harbin also involved measuring our temperatures. Also mandatory was blood-work for detecting HIV (if positive, you're deported). Everything else was optional, and thus quickly passed upon. You'd understand if you saw the inside of the place. The place was dirty and dusty, some trash not bothered to be placed in a bin, some of it medical waste (eg. blood-stained cotton held in the arm after having blood drawn). There were some chairs lining the hallway near the main doctor's office, some of which had little spots on the wall behind them where presumably a patient with a head injury was leaning. Just as I noticed the giant no-smoking banner above the entrance to our wing, a doctor appeared from around the corner to take his cigarette, drop it to the floor, and stamp it out.

This is all typically “dirty” stuff that you'd come to expect in a coal-powered, rubble-lined, industrial city such as Harbin, but the icing on the cake for me was watching the nurse take blood. I volunteered to go first because I wasn't sure if they'd be re-using the needle or not. I watched carefully as she used an alcohol swab to clean the site on my arm, and then it dawned upon me that she wasn't wearing any gloves. “Shiiiiiiit,” I was thinking, but it's simply bad timing to start an argument after someone's already stabbed into you. She got her vials and I got my complimentary ball of cotton. I just hoped I didn't wind up getting anything else from her...

Everybody poops, you know.

The last part of our visit was the mandatory check for H1N1 symptoms as recently directed by the government. This was done with a mercury thermometer to the armpit. Apparently they only had one in our hospital, so we had to take turns. As it turns out, our party contained one lass with a fever, a common symptom of.. well, almost anything - including H1N1. She was soon separated from our group and our interpreter informed us that Patient Zero would be asked to wait in another room to administer further tests.

An hour later, the situation hadn't changed except for the location of our friend. And instead of a room in our hall, she'd been relocated to the “quarantine” section of the hospital. I called her cell phone to ask where exactly that was. She replied that it was some old, dusty wing that had fallen into disuse. Further, she was by herself, with no staff (and more worryingly, our interpreter) nearby. Needless to say, she was in a bit of a panic, and I tried my best to reassure her. Soon after my phone call ended, the rest of us foreigners were asked by a nurse to move into a different room, thankfully nearby and with plenty of medical devices to inspect and play with.

Another two hours later, little had changed except for our blood pressures. Left to our own thoughts, we tried to account for all of the different scenarios that might play out. I was on the phone with a number of people during this time, trying to collect as much information for our strategizing as possible. If weeks-long quarantine was their prerogative, we wouldn't be going without a fight. (Note to self: upon arrival in a new country, add embassy phone number to contacts list.) To our surprise, the nurses came in to equip us with medical masks (occasionally worn by Chinese who are sick as a courtesy to others, or by those who fear contracting something) before leading us out the door and down the hall back to the entrance. And who was waiting there for us but Patient Zero herself! She was pretty shaken up, and for good reason as I later learned that all of her interactions for the past hours were with non-English speakers wearing hazmat suits.

I now wonder if those suits had been washed in-between deployments...

Now that we were all back together, the “crazy” part of the story can be heard. Yes, prior to this spectacular ending, the rest of it makes quite a lot of sense. When I had last talked to my boss, he said we'd all be taking separate taxis home. What was presented to us at the hospital entrance was an ambulance - lights flashing - doctors and nurses running about the lobby, and a swarm of onlookers outside. I didn't realize the Chinese national past-time of rubber-necking until much later into my stay, but damn. The answer to the rhetorical question “don't you have anything better to do?” is clearly a “no!” (Unemployment statistics would back up this observation.) Many of the people in Harbin react to any foreigner-spotting by staring or shouting out a “hallo” and then immediately cracking up amongst themselves. Well, here were five of us all raising hell at a hospital in the middle of the day on a busy corner. It was practically a media event. We reluctantly climbed into the back of the ambulance - thinking anywhere was better than there - only to spot our chauffeurs were equipped with hazmats as well.

Shit. This is not what we were told would happen.

The ambulance took off for who-knows-where at ludicrous speed. At this point, all I could do was look out the side window and smile - not that anyone would be able to tell because of the surgical mask. As we wove through traffic, we were stopped at a light for about a minute as a bus-full of passengers stared on in horror at what they must've thought was a plaguemobile. We waved back. After a while, we came to a familiar, large T-shaped intersection that I recognized from walking to one of our schools. The drivers were suddenly arguing and making animated gestures in the front, and after some less-than-legal maneuvering, we were stopped on the area of sidewalk nearest the crossroads. At this point, all of us were looking at one another, silently thinking the same thing: “they can't be letting us out here.”

The back doors swung open to reveal one of our hermetically-sealed escorts. Indeed, he motioned for us to get out.

I sure as hell wasn't going to refuse the offer. Sticking around any longer with Bubble Boy would only increase the chances of yet another phone call informing him of yet another change of plans, this time with me winding up in the confines of a hospital room instead of my apartment.

I'd had plenty of time to think in the back of the meat-wagon. As soon as my turn came up, I darted out of the back and ran a 100-meter dash to the first corner. As I turned, I pulled off the face mask and switched to a calm stride so as not to alarm anyone else who didn't just watch an ambulance-full of foreigners taking part in a scene straight out of a survival-horror movie. I kept on walking calmly away and periodically checking my tail for... I don't know what. Something strange, I guess... as if things could have become any stranger at that point. I finally sat down somewhere and bought an ice-cream. Strawberry, fuck yea.

Unfortunately, the obvious consequence of the power of guanxi in situations such as these also necessitates having it. For instance, there are plenty of hospitals and doctors in Harbin, but for the typical workers here, access to them is prohibitively expensive. Median monthly wages are about 1-2,000 RMB, yet health care is privatized and the majority of workers don't have insurance or benefits. The occasions I was sick enough to visit a doctor this past year resulted in hundreds of RMB in visitation and prescription fees, and for very basic issues. This is why many Chinese here absolutely hoard money. Savings rates of more than 70% (of their monthly wages going to a bank) aren't uncommon! Thus, if you fall victim to a severe illness or accident, having a doctor in your guanxi network can literally mean the difference between life and death.

Otherwise, you'd better have plenty of cash on hand.

And why is that? This may be a good time to respectfully remind readers that China is a Communist country in history only. Yes, it's currently governed by the Communist Party of China, but like other political groups with a monopoly on power, their stated ideals are merely a lavishly deceptive decoration. The father of Communism in modern China, Chairman Mao, worked hard to vilify and justify the destruction of the “capitalist bourgeoisie” such as academics, entrepreneurs, and competing politicians. Mao was a brilliant leader, tactician, and all-around-revolutionary, but once the dust settled on the battlefields and it was time to attend to his new empire, he couldn't grow the economy ...or even enough crops... to keep it from collapsing back into chaos. And after reading enough about Mao, it seems like that was his idea of a good time - endless revolution.

A short story long: don't read the detached and objective historical accounts of Mao's failed policies such as The Great Leap Forward and the Cultural Revolution. To really understand why China is the way it is today, you must know what the political climate was like then, how neighbors, friends, and families were forced to turn against one another, how they were whimsically persecuted because of ideological minutiae, how millions were murdered or starved. Look deeper, past the statistics and into the stories to understand how the phoenix of modern China arose from the ashes Mao left behind. The best book I can currently recommend for this is an engaging account from then until now titled, “Chinese Lessons.”

Today, however, China's modern economic system is referred to as “socialism with Chinese characteristics” - a phrase vague enough to be meaningless and thus politically perfect for side-stepping Mao's anti-capitalist propaganda. Coined by none other than Deng Xiaoping, the head-of-state responsible for China's economic awakening. With Deng's eminent quote, “to get rich is glorious,” you don't need to be much of a scholar to detect the about-face in the Communist Party's entire philosophy.

This explains a few of my encounters with the health care system. The most recent time I got a throat infection, I walked with a native-Chinese teaching assistant to the nearest hospital to get checked. We had to pay cash up-front to take a number, then we waited to be called to fill out the patient information and be directed to the appropriate wing and doctor. We journeyed to the “mouth, ears, eyes, & nose” section, found the doctor's office, popped in, and placed our papers next on the stack of other patients and began the next wait in the hall outside. As mentioned, this is all normal - there is no expectation of privacy, as the door has always been left open and people often stand in the very same room to jockey for the next position in line or just because they're curious about what's lodged up the next guy's nose.

In my particular scenario, I sat down with the doctor and she took a look by holding some gauze to pull my tongue out (thankfully, this doctor was wearing gloves), and saw the same horror that led me to go there in the first place. She made some disparaging sounds and remarked to my escort that it was “really bad.” I asked her what it was and she replied that I'd need to stay in the hospital for 5 days. This wasn't exactly the kind of response I'd expected. They could perform a complete tonsilectomy and I wouldn't need to stay for 5 days - but I asked again if she knew what it was. She couldn't say; they'd have to do some tests while I stayed with them. What bullshit, I thought - a throat swab takes minutes. Maybe she wanted to grow some cultures while I waited in a hospital bed, but instead I had the feeling that I'd wake up the next day with a bill for a missing appendix. When I insisted on the information she had under that hair-net that justified a 5-day internment, this now-debatable doctor quickly became indignant. Whether she was a mail-order-degree quack or a genuinely skilled doctor who wanted some extra cash, there was no way I was going to entertain that bullshit any longer. At that moment, I understood with absolute clarity why one of my mentors here (who is fluent, married to a Chinese wife, and takes his kid to the hospitals here) said that it took a Herculean amount of self-restraint “NOT to punch the doctor in the fucking face” when dealing with this kind of ignorance ...or outright scamming.

Ah, but perhaps the next foreigner won't be so lucky and will cave in to the fear-tactics and pay for the 5-day deluxe stay. Oh, yes, what a fat commission that would bring in! Indeed, “to get rich is glorious!”

The assistant and I talked on our way back from the hospital and she mentioned that there was a better one we could go to later that week. I wasn't particularly convinced by the word “better,” but I asked anyway. Her mother was staying at this other hospital after some minor surgery. We got to talking about the state of health care in China and America and I mentioned something I'd heard about surgery here: is it true that prior to the operation, one should give the surgeon a “gift?” Why, yes, as a matter of fact. It's quite common. I asked what she gave. “An envelope with 1,000 yuan.” In other words, almost her entire month's salary. I don't know how much others spend or what can happen to those who don't, so I probably shouldn't make any judgements with so little information, right?

Yet, the one recurring thing I do know about Chinese health care, it seems, is that “to get rich is glorious!”

In the end, I solved my problem by talking to my manager ..who knows a guy ..who knows a gal ..who knows everybody. The next day, we were walking into a doctor's private office without taking a number, shaking hands, and talking about throat infections as the best of old buddies would. I was given a mild dosage of penicillin, and after a few days when a previously-unknown allergic reaction covered my body in red spots and caused my face to swell so that my inner lips were painfully split, we met again to discuss trying another anti-biotic. It was alright, though. There were some cute nurses who adored the novelty of a polka-dotted foreigner answering their questions in Chinese. I wouldn't have minded staying under their care for 5 days! The last set of doctors to inspect my (now two) conditions were at the top of their game. The assistant assured me of this because she'd overheard some of the earlier phone call between those nurses and none other than the hospital's director.

So, I followed all of their suggestions, took all of the pills, and made a full recovery within a week. Oh, guanxi, you card!